DILLON SCHOOL DISTRICT FOURDISCIPLINE INCIDENT AND REFERRAL FORM

Student:______
Referring Staff Member:______
Title/Code:______
Student’s Teacher: Date: / Grade: : Pre K K 1 2 3 4 5 6 7 8 9 10 11 12
School: EES SES SHE GES DMS
DHS LVE LVH
LocationCodes(Check onlyone location code.)
Bus (BUS) / Cafeteria (CAF) / Classroom (CLS) / Gym (GYM)
Hallway/Stairs (Hal) / Media Center (MDC) / Off School Property (OFF) / Rest Room (RRM)
Yard/Playground ( YRD) / Parking Lot (PKG) / School Function (SCF) / Administrative Area/Office
Time Codes(Check only one time code.)
In School
DSH(During School Hours)
Time:______/ (BBB) Bus / (BCL) Before Class / (DCL) During Class
(BWC) Between Classes / (DSA) School Sponsored Activity / (ACL) After Class
(LUN) Lunch
Out of School
OUT (Outside School Hours) / (OSA) School Sponsored Activity / (ONA) Non-School Sponsored Activity

(To Be Completed by Person Referring Student)

Problem Behaviors _____First Offense _____Recurring Description of the problem, including evidence of recurring problems:

______

______

______

______

______

Additional Information (Completed by PowerSchool Personnel):

Special Education Status:
_____ Active (Notify Special Services prior to removal) _____ Referred _____Not Suspected of Having a Disability under IDEA
Number of previous referrals this year:______
Number of removals (OSS and/or ISS) this year: ______
Student is under an Attendance Order from the Family Court
______Yes (Notify Carmen Bethea) ______No

Student Conference Documentation: Time of Conference: Date:

I have conferenced with this student, notifying him/her of the infractions contained herein.
Principal: / I have been notified of the infractions against me and been given an opportunity to present my views.
Student: / Parent: Please sign to acknowledge your receipt and return to the school
Parent:

Documentation of Removal Due Process: Dates of Suspension (ISS OR OSS)______

Dear Parent: A conference to discuss this discipline referral and the actions taken by the school is scheduled for ______(Date) at ______(Time) at the school. It is very important that you attend this conference to discuss the issues in this notice. If this date is not acceptable to you, please call immediately to establish a mutually agreeable time.

Documentation of Parent Conference andProposed Remedies:

______

PrincipalParent/Guardian

Notice Mailed to Parent By Regular Mail on (Date) ______.

Response Received ___Yes ___No

If no response in 48 hours (for suspension only), parent contacted by phone:

______

Person Making Phone CallTimeDate

___Answering Machine ___Busy ___No Answer ___Disconnected

___Answered ______

Information from Parent

Administrative Use
Behavior Code: ______Level 1 Level 2 Level 3 / Administrative Determinations

Behavior Codes (Please Circle)

002 Other Offenses (Minor) (II-B) / 350 Fire Alarm (III-A)
003 Bite/Pinch/Spit (I-D) / 360 ID Violation (1-A)
004 Contraband (1-D) (I-E) / 370 Littering (I-D)
005 Detention Violation (I-F) / 380 Probation Violation (III-A)
006 Dishonesty (I-D) / 390 Unauthorized Device (I-G)
007 Disrupting Class (I-F) / 400 Excessive Noise (I-F)
009 Fighting (II-B) (III-A) / 410 Hall Pass Violation (1-A)
010 Fireworks (III-A) / 420 Disrespect (I-F)
011 Forgery (I-F) / 430 Contract Violation (III-A)
012 Harassment (I-F)
Due to Race of Victim
Due to Disability of Victim
Due to Gender of Victim
Due to Religion of Victim
Other/Unknown / 500 Arson (III-A)
013 Sexual Harassment (II-B) / 510 Assault, Aggravated (III-B)
014 Hit/Kick/Push (I-D) / 520 Assault, Simple (III-A)
015 Inappropriate Affection (II-B) / 530 Bribery (III-A)
016 Inappropriate Language (I-E) (II-B) / 540 Burglary (III-A)
017 Inappropriate Behavior (I-D) / 550 Counterfeit/Forgery (III-A)
018 Inappropriate Materials (I-D) / 560 Disturb School (I-F) (III-A)
019 Indecent Exposure (III-A) / 570 Drug Distribution (III-B)
020 Major Disruption (II-A) / 575 Drug Usage
021 No Form Return (I-A) / 580 Drug Possession (III-A)
023 Property Misuse (II-B) (III-A) / 590 Embezzlement (III-A)
024 Running (I-D) / 600 Extortion (III-A)
025 Sex Violation (III-A) / 610 Forced Sex Offense (III-A)
027 Threat (I-F) / 620 Fraud (III-A)
028 Throwing Objects (II-A) / 630 Gambling (III-A)
029 Urination (III-A) / 640 Homicide (III-B)
030 Violation of Class Rules (I-A) / 650 Intimidation (II-B)
150 Cutting School (I-F) / 651 Bullying (II-B)
Due to Race of Victim
Due to Disability of Victim
Due to Gender of Victim
Due to Religion of Victim
Other/Unknown
151 Truant (I-F) / 652 Cyberbullying (II-B)
152 Habitual Truant (I-F) / 660 Kidnapping/Abduction (III-B)
153 Chronic Truant (I-F) / 670 Larceny/Theft (III-A)
160 Cutting Class (I-F) / 680 Alcohol/Liquor Law Violation (II-B) (III-A)
170 Cutting Activity (I-F) / 690 Non-Forced Sex Offense (II-B)
180 Tardy (1-B) / 700 Other Offenses (Serious) (II-B) (III-A)
200 Off Limits/Unauth Area (I-E) / 730 Robbery (III-A)
210 Profanity (I-E) / 740 Stolen Property (III-A)
220 Computer Violation (II-B) (III-A) / 750 Trespassing (II-B)
230 Tobacco Violation (II-A) / 760 Vandalism (II-A) (III-A)
240 Loitering (I-F) / 770 Vehicle Theft (III-A)
250 Gang Activity (II-B) (III-A) / 780 Other Weapons (III-B)*
260 Bomb Threat (III-B) / 781 Handguns (III-B)*
270 Refusal to Obey/ Defiant (II-A) / 782 Rifles/Shotguns (III-B)*
271 Failure to Comply with Disc Action (II-A)
Comm Serv/Work Detail
Detention
In-School Suspension
Other / 783 Other Firearms (III-B)*
280 Dress Code Violation (I-C) / 784 Knifeblade>2 (State) (III-B)*
290 Obscene Gesture (I-D) / 785 Knifeblade>2.5 (Federal) (III-B)*
300 Parking/Driving Violation (III-B) / 786 Knifeblade Less Than 2 (III-B)*
310 Leaving School (I-F) / 789 Weapon (Specify Object) (III-B)
320 Leaving Class (I-F)
330 Phone Violation (I-G)
340 Bus Violation (I-H)

*ObjectCodes

Action Codes (Please Circle/Write In, if action has line for entry)

Alternative PlacementExpulsionReferred to Alternative Program

Location/Duration ______ No Services Provided

 Services ProvidedRestraint

Arrested Mechanical

Family Court Referral Physical

Behavioral Contract/Plan  Seclusion

Hearing

Bus Suspension and Duration ______ AdministrativeSuspension

 Alternate Transportation (District) Expulsion Concurrent Suspension

 Alternative Transportation (Parent/Guardian) Manifestation Determination In-School (No Services Provided)

 No Alternative Transportation In-School (Services Provided) Home Visit  Out of School (No Services Provided) Call to Law Enforcement  Out of School (Services Provided) IDEAS IAES  Pending Expulsion

Call to Parents Hearing Officer Pending Parent Conference

 Unilateral Removal Recommended for Expulsion

Community Service/Work Detail

Intervention PlanTransfer

ConferenceLocation ______ Parent Juvenile Court

 StudentViolation of Court Order

 Conference with BothLetter to Parent

 MultidisciplinaryWarning

Payment for Damages

ConfiscatedWithdrawal of Privileges

Probation Activities

Court Ordered Attendance Computer

Referral Parking

Detention and Duration ______ Administration Driving

 After School Adult Education

 Saturday County Alcohol Program

 Lunch DSS

 Recess Mental Health

 Other School Counselor

Revised 7/31/2013